Assessment of Soft Tissue Facial Profile, Nasal

Assessment of Soft Tissue Facial Profile, Nasal Airway Morphology and Dental Arch Features in Adult Malay Obstructive Sleep Apnea Patients using Geometric Morphometric Analysis

SAEED MOHAMMED SAEED BANABILH

Universiti Sains Malaysia 2008

Assessment of Soft Tissue Facial Profile, Nasal Airway Morphology and Dental Arch Features in Adult Malay Obstructive Sleep Apnea Patients using Geometric Morphometric Analysis

by

SAEED MOHAMMED SAEED BANABILH

Thesis submitted in fulfillment of the requirements For the degree of Doctor of Philosophy

December 2008

Obstructive Sleep Apnea Acknowledgment __________________________________________________________________________________

Acknowledgment

Praise be to Allah s.w.t., the most compassionate and most merciful, whose blessing have helped me throughout the study until the completion of this thesis.

This research project would not have been possible without the support of many people. The author wishes to express his gratitude to Professor Dr. Dinsuhaimi Sidek who was very helpful and offered invaluable assistance, support and guidance. Deepest gratitude are also due to Professor Dr. Ab. Rani Samsudin, former Dean, School of Dental Sciences and Senior Consultant Maxillofacial Surgeon, USM, who helped in designing the study and for his encouragement and support.

I gratefully thank Dr. Suzina Sheikh Abd. Hamid for her advice, supervision, and crucial contribution. Special thanks also goes to Professor GD Singh, former USM Visiting Professor, who helped in designing the study, his commitment, encouragement, enthusiasm and skills that gave me a great foundation for my study.

Special thanks also go to Associate Professor Dr. Hj. Abdul Rashid Hj. Ismail, Dean of School of Dental Sciences for his support throughout the study, to the Head of ORL-HNS Department Dr. Rosdan Salim for his support and homely environment and to the Head of Plastic and Reconstructive Unit Professor Ahmad Sukari for use of the 3dMD system.

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Obstructive Sleep Apnea Acknowledgment __________________________________________________________________________________

The author would also like to convey thanks to Dr. Ahmad Burhanuddin Abdullah, Consultant Orthodontist, Kota Bharu Dental Clinic, Kelantan, for his clinical skills and guidance, knowledge and support that gave me a great foundation in clinical orthodontics. I grant my grateful appreciation and sincere thanks to Dr. Mohd Ayub Sadiq for his expert analytical and mathematical contributions to this study.

I wish also to thank Dr. Hazama Mohamad, ORL-HNS Specialist, for support with patient’s examination and Dr. Zainul Ahmad Rajion, for his support throughout the study.

The authors would like to thank also Sleep Sciences Laboratory technicians, Yusman, Suhylah and Eda for their time, efforts, and help. Special thanks go also to Miss Ida, my research assistance who worked hard during the data collection and to all staff, nurses, dental officers and research officers of Dental and Medical School, USM.

I wish to acknowledge with special thanks the support given to me throughout the work by the members of my family; particularly my parents and my wife who I pay highest tribute to her for her continued love and encouragement and to my daughter Lujain and my sons Mohammad and Mohanad.

Special thanks also to all graduate friends, classmates, fellow residents and friends, for sharing the literature and invaluable assistance. To all named and unnamed helpers and friends, I again extend my thanks.

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Obstructive Sleep Apnea Acknowledgment __________________________________________________________________________________

Finally, I would like to express my thanks to Universiti Sains Malaysia for the financial support (short term research grant No. 304/PPSP/6131489), and University of Science and Technology (Yemen) for their delightful support.

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We live in a sea of apnea; the sleep centre can be a life saver Lyle D. Victor

Obstructive Sleep Apnea

Table of Contents

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Obstructive Sleep Apnea

Table of Contents

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TABLE OF CONTENTS

Acknowledgements ................................................................................... ii Table of Contents ..................................................................................... v List of Tables ......................................................................................... xvi List of Figures ...................................................................................... xviii List of Abbreviations ........................................................................... xxii Abstrak ................................................................................................. xxvi Abstract ................................................................................................ xxix

CHAPTER 1 INTRODUCTION ......................................................... 1 1.1

Background .............................................................................................. 1

1.2

Prevalence of Obstructive Sleep Apnea ................................................... 3

1.3

Classification of Sleep Apnea .................................................................. 5 1.3.1

Obstructive Sleep Apnea ........................................................... 5

1.3.2

Central Sleep Apnea.................................................................. 6

1.3.3

Mixed Sleep Apnea ................................................................... 6

1.3.4

Sleep Hypopnea ........................................................................ 7

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1.4

Obstructive Sleep Apnea and Hypopnea Indices ..................................... 7

1.5

Upper Airway Resistances Syndrome...................................................... 8

1.6

Risk Factors Associated With Obstructive Sleep Apnea ......................... 9

1.7

1.6.1

Gender and Age......................................................................... 9

1.6.2

Obesity .................................................................................... 13

1.6.3

Nasal Obstruction .................................................................... 16

1.6.4

Family History ........................................................................ 17

1.6.5

Ethnicity .................................................................................. 18

1.6.6

Smoking and Alcohol.............................................................. 19

1.6.7

Genetic .................................................................................... 19

Consequences Effect Of Obstructive Sleep Apnea ............................... 20 1.7.1

Motor Vehicle and Occupational Accidents ........................... 21

1.7.2

Hypertension and Cardiovascular Morbidity .......................... 21

1.8

Statement of the Problem ....................................................................... 23

1.9

Objectives and Hypothesis ..................................................................... 24

1.10

1.9.1

General Objectives .................................................................. 24

1.9.2

Specific Objectives.................................................................. 24

1.9.3

Research Hypotheses .............................................................. 24

Significance of the Study ....................................................................... 25

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CHAPTER 2 LITERATURE REVIEW ............................................ 27 2.1

Overview ................................................................................................ 27

2.2

Pathogenesis of Obstructive Sleep Apnea ............................................. 27 2.2.1

Anatomical and Craniofacial Factors ...................................... 29

2.2.2

Pharyngeal Muscles Factors.................................................... 32

2.2.3

Other Potential Factors Effecting Upper Airway

Collapse... ............................................................................................... 33 2.3

Obstructive Sleep Apnea Diagnostic Methods ...................................... 34 2.3.1

2.4

History ..................................................................................... 35 2.3.1.1

Snoring .................................................................. 35

2.3.1.2

Excessive Daytime Sleepiness ............................. 36

2.3.1.3

Witnessed Apneas and Nocturnal Choking .......... 37

2.3.2

Clinical and Physical Examination. ........................................ 37

2.3.3

Clinical Prediction Models...................................................... 39

2.3.4

Morphometric Prediction Models. .......................................... 41

2.3.5

Polysomnography (PSG)......................................................... 42 2.3.5.1

Full Attended Standard Polysomnography ........... 43

2.3.5.2

Full Unattended Standard Polysomnography........ 46

2.3.5.3

Limited Channels Polysomnography .................... 47

2.3.5.4

Portable Home Polysomnography......................... 49

Assessment of Obstructive Sleep Apnea Craniofacial and Soft Tissue

Features………………………………………………………………………52 2.4.1

Cephalometric Assessment Technique. .................................. 53

2.4.2

Geometric Morphometric Assessment Techniques ................ 54 2.4.2.1

Overview .............................................................. 54

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2.4.2.2

Classification of Geometric Morphometric Assessment Techniques ........................................ 56 A) Boundary Outline Techniques ........................ 56 B) Landmark Based Techniques .......................... 56 i) Procrustes Analysis......................................... 57 ii) Thin Plate Spline Analysis (TPS) .................. 58 iii) Finite Element Scaling Analysis (FESA) ...... 59

2.4.2.3

Geometric Morphometric Characteristics of OSA Patients ........................................................ 62

2.5

Obstructive Sleep Apnea Upper Airway Features ................................. 64 2.5.1

Pharyngeal Airway in Patients with OSA ............................... 65

2.5.2

Upper Airway Imaging Techniques ....................................... 67 2.5.2.1

Cephalometry ....................................................... 68

2.5.2.2

Nasopharyngoscopy ............................................. 69

2.5.2.3

Fluoroscopy .......................................................... 69

2.5.2.4

Computerized Tomography and Magnetic Resonance Imaging ............................................. 70

2.5.3

Nasal airway Acoustic Rhinometry Techniques ..................... 71 2.5.3.1

Overview .............................................................. 71

2.5.3.2

Acoustic Rhinometry Curves ................................ 72

2.5.3.3

Acoustic Rhinometry Accuracy ........................... 73

2.5.3.4

Acoustic Rhinometry and Rhinomanometry ......... 74

2.5.3.5

Acoustic Rhinometry Findings in SleepDisordered Breathing ............................................ 76

2.6

Obstructive Sleep Apnea Dental Arch Features..................................... 77

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CHAPTER 3 MATERIALS AND METHODS ................................ 80 3.1

Study Design .......................................................................................... 80

3.2

Population and Sample........................................................................... 80

3.3

3.2.1

Reference Population ............................................ 80

3.2.2

Source Population ................................................. 80

Sampling Frame ..................................................................................... 81 3.3.1

Inclusion Criteria..................................................................... 81

3.3.2

Exclusion Criteria.................................................................... 81

3.3.3

Sampling Methods .................................................................. 82

3.3.4

Sample Size ............................................................................. 82 3.3.4.1

Sample Size Calculation for the First Objective .............................................................. 82

3.3.4.2

Sample Size Calculation for the Second Objective .............................................................. 83

3.3.4.3

Sample Size Calculation for the Third Objective .............................................................. 83

3.4

Overview of Data Collection Procedure ................................................ 84

3.5

Research Tools and Study Parameters ................................................... 87 3.5.1

Clinical Examination ............................................................... 87 3.5.1.1

General Examination............................................. 87

3.5.1.2

Physical Examination ............................................ 88 i) Neck Circumferences (NC) .............................. 88 ii) Body Mass Index (BMI) ................................... 88 iii) Nasal and Oropharyngeal Examination ........... 88 iv) Extra- and Intra-Oral Examination .................. 90

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a) Facial Profile Examination......................... 90 b) Malocclusion Classification ....................... 92 c) Palatal Morphology .................................... 92 3.5.2

Limited-Channels Polysomnography (PSG) ........................... 93 3.5.2.1

Overview ............................................................... 93

3.5.2.2

Components of the Embletta Portable Diagnostic System................................................. 96 I) External Sensors ................................................ 96 1) Abdominal and Thoracic Sensors ................ 96 2) Snoring Sensor ............................................. 97 3) Oximeter Sensor .......................................... 97 i) Oxygen Saturation Signals ................... 98 ii) Pulse Signals ........................................ 98 iii) Pulse Waveform Signals..................... 98 iv) Beat-To-Beat SpO2 Signals ................ 98 II) Built-In Sensors.................................................. 99 1) Nasal Airflow Pressure Transducer ............. 99 2) Body Position Sensor ................................... 99 3) Actigraph Sensor........................................ 100

3.5.2.3

Embletta Portable Diagnostic System Recording Parameters ......................................... 100 i) Overview ........................................................ 100 ii) Nasal Airflow Parameters .............................. 102 iii) Snoring Parameters........................................ 102 iv) Body Position Parameters .............................. 102

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v) Thoracic and Abdominal Parameters ............. 103 vi) Oximeter Parameters ..................................... 103 3.5.3

Stereophtogrammetry 3D System ......................................... 104 3.5.3.1

Overview of 3D Stereophtogrammetry ............... 104

3.5.3.2

Overview of 3dMD Technology ......................... 105

3.5.3.3

Components of 3dMD System ............................ 105 A) 3dMD Capturing Device ................................ 105 B) 3dMD Acquisition Device ........................... 106

3.5.3.4

Imaging Procedure of 3dmd System ................... 106 i) Alignment Procedure ...................................... 106 ii) Subject Position .............................................. 107 iii) Image Acquisition, Generation and Display ................................................................ 107 iv) Image Processing and Data Transfer ............. 107

3.5.4

Acoustic Rhinometry Instrument .......................................... 109 3.5.4.1

Overview ............................................................. 109

3.5.4.2

Acoustic Rhinometry Instrument and Technology .......................................................... 110

3.5.5

3.5.4.3

Acoustic Rhinometry Procedure ......................... 111

3.5.4.4

Acoustic Rhinometry Rhinogram ....................... 113

3.5.4.5

Data Processing and Transfer ............................. 114

Dental Study Models and Image Records ............................. 115 3.5.5.1

Dental Cast Position ............................................ 116

3.5.5.2

Imaging Procedure .............................................. 116

3.5.5.3

Images Processing and Data Transfer ................. 116

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3.6

Data Analysis ....................................................................................... 118 3.6.1

Statistical Analysis ................................................................ 118

3.6.2

Geometric Morphometric Analysis ....................................... 118

3.6.3

Geometric Morphometric Analysis Using Morphostudio

Software… ........................................................................................... 119 3.6.3.1

Overview ............................................................. 119

3.6.3.2

Data Digitizer Procedure Using Morphostudio Software....................................... 122 i) Data Digitizer Procedure for Soft Tissue Facial Profile ....................................................... 122 ii) Data Conversion Procedure for Nasal Airway Morphology ............................................ 124 iii) Data Digitizer Procedure for Upper and Lower Dental Study Models ............................... 125

3.6.3.3

Data Analysis Procedure Using Morphostudio Software....................................... 128 i) Dense Correspondence Analysis .................... 129 ii) Procrustes Analysis ........................................ 132 iii) Inter-Landmark Distances Analysis .............. 134 iv) Finite Element Analysis................................. 134

3.6.4

Reliability of Research Measurements.................................. 137 3.6.4.1

Overview ............................................................. 137

3.6.4.2

Reliability of the Measurements ......................... 138 i) Facial Soft Tissue Landmarks ........................ 139 ii) Acoustic Rhinometry Measurements............... 140 iii) Dental Cast Landmarks ................................. 141

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CHAPTER 4 RESULTS AND DISCUSSION ................................ 142 RESULTS .................................................................... 142 4.1

Overview .............................................................................................. 142

4.2

Statistical Findings ............................................................................... 144 4.2.1

Demographic Profiles of the Study Subjects ........................ 144

4.2.2

Clinical Examination ............................................................. 146 4.2.2.1

Polysomnography and Physical Examination Findings ............................................................... 146

4.3

4.2.2.2

Nasal and Oropharyngeal Examination .............. 148

4.2.2.3

Extra- and Intra-Oral Examination...................... 149

Geometric Morphometric Findings ...................................................... 150 4.3.1

4.3.2

Facial Soft Tissue Configurations ......................................... 150 4.3.1.1

Procrustes Analysis ............................................. 150

4.3.1.2

Inter-Landmark Distances Analysis .................... 153

4.3.1.3

Finite Element Analysis ...................................... 155

Nasal Airway Configurations ................................................ 157 4.3.2.1

Nasal Airway Statistical Findings ....................... 157

4.3.2.2

Nasal Airway graphical Findings ........................ 159

4.3.2.3

Nasal Airway Geometric Morphometric Findings ............................................................... 161 i) Procrustes Analysis ............................ 161 ii) Finite Element Analysis..................... 162

4.3.3

Dental Arch Configuration.................................................... 163 4.3.3.1

Procrustes Analysis ............................................. 163 i) Upper Dental Arch Configuration .................... 163

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ii) Lower Dental Arch Configuration.................... 166 4.3.3.2

Inter-Landmark Distances Analysis .................... 168 i) Upper Dental Arch Configuration .................... 168 ii) Lower Dental Arch Configuration.................... 170

4.3.3.3

Finite Element Analysis ...................................... 172 i) Upper Dental Arch Configuration .................... 172 ii) Lower Dental Arch Configuration.................... 175

DISCUSSION ............................................................. 177 4.4

Methodological Discussion .................................................................. 179

4.5

Clinical Examination Discussion ......................................................... 184

4.6

4.5.1

Polysomnography Data and Physical Examination .............. 184

4.5.2

Nasal and Oropharyngeal Examination ................................ 188

4.5.3

Extra- and Intra-Oral Examination........................................ 190

Geometric Morphometric Discussion .................................................. 195 4.6.1

Facial Soft Tissue Configurations ......................................... 195

4.6.2

Nasal Airway Configuration ................................................. 199

4.6.3

Dental Arch Configuration.................................................... 212

CHAPTER 5 SUMMARY AND CONCLUSION ........................... 219 5.1

Summary .............................................................................................. 219

5.2

Novelty of the Research Project ........................................................... 224

5.3

Clinical Implication .............................................................................. 226

5.4

Limitations ........................................................................................... 228

5.5

Future Studies ...................................................................................... 230

5.6

Conclusion ........................................................................................... 232

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REFERENCES ................................................................................ 233 APPENDICES ................................................................................. 262 PUBLICATION LIST .................................................................... 278

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Obstructive Sleep Apnea List of Tables __________________________________________________________________________________

LIST OF TABLES

Tables

Title

Page

Table 3.1

Definition and position of soft tissue landmarks

122

Table 3.2

Upper and lower dental arch landmarks

126

Table 3.3

Inter-landmark distances used for upper and lower dental arches

127

Table 3.4

Reliability of 3D facial soft issue landmarks

139

Table 3.5

Acoustic rhinometry reliability measurements

140

Table 3.6

Reliability of 2D dental cast landmarks

141

Table 4.1

The distribution of study subjects according to age and sex

145

Table 4.2

The distribution of study subjects according to gender and OSA severity

145

Table 4.3

The distribution of study subjects according BMI and OSA severity

147

Table 4.4

Polysomnography and physical examination findings

147

Table 4.5

Clinical observation of nasal and oropharyngeal variables

148

Table 4.6

Clinical observation of facial profile, malocclusion class and palatal shapes variables

149

Table 4.7

Acoustic rhinometry statistical findings

158

Table 4.8

Definitions of significant landmarks of OSA and control upper dental arch configurations

164

Table 4.9

Significant regions (triangle) of OSA and control upper dental arch configurations using Procrustes coordinates

165

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Table 4.10

Definitions of significant landmarks of OSA and control lower dental arch configurations

166

Table 4.11

Significant regions (triangle) of OSA and control lower dental arch configurations using Procrustes coordinates

167

Table 4.12

Inter-landmark distances analysis for the upper arch showing statistically significant regions (p < 0.05)

169

Table 4.13

Inter-landmark distances analysis for the lower arch showing statistically significant regions (p